For Pain or Not for Pain: Methadone Madness Maria Foy, PharmD, BCPS, CPE Clinical Specialist Palliative Care Abington Memorial Hospital mfoy@amh.org

Objectives Differentiate the use of methadone for pain vs. addiction management Explain information needed to verify a methadone dose for addiction management

Methadone History 1939: developed in Germany to be used as an analgesic in WWII 1949: US obtained methadone from the manufacturing company following the war Early 1960’s: heroin epidemic following WWII 1964: research project was conducted studying methadone for addiction treatment to try to combat the increase abuse of heroin

Patient Case: LO is a 27 year old female who enters the emergency department. She is currently addicted to heroin and recently found out she was pregnant. Currently, patients cannot be admitted to an inpatient facility for heroin detoxification without a special license. Would you allow this patient to be admitted for detoxification in your institution?

Key Policy Elements Define ordering and dispensing processes based on indication of use Analgesia Maintenance therapy for patients enrolled in an Outpatient Treatment Program (OTP) Short term treatment of acute withdrawal in a current opioid abuser if admitted for an alternate medical diagnosis

Key Policy Elements Restrict pain indication use to experts trained and experienced with analgesic use Exception: Unrestricted ordering allowed for patients receiving methadone prior to admission

Key Policy Elements Assure compliance to regulatory agency standards Drug Enforcement Agency (DEA) Substance Abuse and Mental Health Services Administration (SAMSHA) Commonwealth of Pennsylvania

Monitoring Data Time frame: 6 months Total orders reviewed: 105 Clarifications: 11

Methadone Safety: A Clinical Practice Guideline From the American Pain Society and College on Problems of Drug Dependence, in Collaboration With the Heart Rhythm Society Published, April 2014: Key Recommendations Patient Assessment: Patient selection should be based on a thorough history, review of medical records and physical examination. Use assessment results to stratify patients based on their risk for substance abuse, co-morbidities, and drug interactions. Education and Counseling: Counsel patients about potential risks and benefits prior to beginning therapy. Advise patients to take methadone as prescribed and comply with follow up monitoring. Notify caregivers about risks for respiratory depression. Baseline Electrocardiograms: Perform ECG exams prior to initiating methadone therapy due risk for QTc interval prolongation.

Guidelines, cont. Alternative Medications: Consider buprenorphine as an option for patients being treated for opioid addiction with risk factors for prolonged QTc intervals. Low Beginning Dose: Methadone treatment should be started at low doses (no more than 30-40 mg daily) and titrated slowly. Urine Drug Testing: Urine drug testing should be performed before initiating therapy and at regular intervals for patients treated for opioid addiction.

Conclusions Development of an institutional methadone policy and order set with decision support has promoted safe and effective use of methadone at our institution Daily review of methadone orders by a pain specialist led to early identification of potential errors

References Pasero C, McCaffrey M. Pain Assessment and Pharmacologic Management. St. Louis, Missouri. Elsevier. 2011. 339-349 McPherson M. Demystifiying Opioid Conversion Calculations. Bethesda, MD. American Society of Health Systems Pharmacists. 2010. 137-143 Federal Narcotic Addict Treatment Act of 1974 (P.L. 93-281) Title 21, Code of Federal Regulations, Section 1306 [39 FR 37986, October 25, 1974). Chou R, Cruciani R, Fiellin D, et.al. Methadone Safety: A Clinical Practice Guideline From the American Pain Society and College on Problems of Drug Dependence, in Collaboration With the Heart Rhythm Society. The Journal Of Pain. 2014. 15(4): 321-337 Boutwell A, Rich J. Inpatient Management of the Active Heroin User. Resident and Staff Physician. 2007. 53(3) 1-5